Left main coronary intervention with a support of intra-aortic balloon pump

- Operator : Seung-Jung Park

Left main coronary intervention with a support of intra-aortic balloon pump
- Operator: Seung-Jung Park, MD
A 69 year-old woman was admitted with resting chest pain for 3 months. Her coronary risk factor was hypercholesterolemia. Echocardiography showed normal LV function without regional wall motion abnormality. Because she had the distal left main (LM) disease with the left anterior descending artery (LAD) lesion (Image 1, Image 2), bypass surgery was recommend in the other hospital. However, she went to this hospital for percutaneous intervention rather than bypass surgery. For the first time, we inserted an intra-aortic balloon pump (IABP) through the left femoral artery for hemodynamic support during the left main (LM) intervention. IABP was activated at 4:1 pumping rate for prophylactic purpose. Then, an 8F sheath was inserted through the right femoral artery, and the left coronary ostium was engaged with an 8F JL 3.5 catheter. The LAD and left circumflex artery (LCX) were wired with two 0.014 inch Floppy wires. Because intravascular examination from the distal LCX showed normal looking ostial LCX, we planned distal LM stenting with a Cypher crossing the LCX ostium. After the first Cypher stent (3.0 x 28 mm) implantation at the middle LAD (Image 3), the second Cypher stent (3.5 x 23 mm at 12 atm) was deployed at the distal LM crossing the LCX ostium (Image 4). For stent optimization, adjunctive high pressure dilatation was performed with a Stormer balloon (4.0 x 10 mm) to 4.26mm at 12 atm (Image 5). Final angiogram showed a good result [Image 6: contour of the stents(arrow heads) and IABP(arrows), Image 7: the final angiogram]. For this particular case, we experienced that IABP was very useful to maintain hemodynamic stability during the procedure.

Comments

  • Su Hong Kim 2004-11-01 I wonder how do you think to adapt post stent balloon dilatation for the Lcx os, in case of cypher insertion crossing over Lcx?
  • Young-Hak Kim 2004-11-01 As you suggested, final kissing balloon inflation has been performed in the majority of LM bifurcation cases treated with stent crossover technique and having stent-jail at the LCX ostium. However, in this particular case, we recognized through IVUS examinationthat the LCx ostium was not jailed by stent strut or plaque shift. Therefore, final kissing balloon dilatation was not done.
  • carlos fernandez pereira 2004-11-01 after implanting the LCX stent have you dilated with a balloon in LAD stent?.I would maintain clopidogrel for at leas t > 1 year .Also I agre e to treat left main disease. Carlos Fernandez Pereira MD Buenos Aires Argentina
  • Young-Hak Kim 2004-11-02 Because the LCX ostium after LM stenting looked normal with IVUS, we did not put a stent in LCX. Generally, we administer clopidogrel for 6 months after LM stenting with DES.
  • Young-Hak Kim 2004-11-09 We put the stent in the LAD not in the LCX. Image 7 is the view from the superior projection.

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